Enrollment has soared to more than 70 million people since 2014 when the Affordable Care Act began providing billions to states that chose to expand eligibility to low-income adults under age 65. Previously, the program mainly covered children, pregnant women and the disabled.

Unlike Medicare, which is mostly funded by the federal government (with beneficiaries paying some costs), Medicaid is a state-federal hybrid. States share in the cost, and within broad federal parameters, have flexibility to set benefits and eligibility rules.

Though it provides a vital safety net, Medicaid faces five big challenges to providing good care and control costs into the future:
…

The largest urban health systems do worse on government patient satisfaction scores than smaller, non-urban hospitals according to a new study by Mount Sinai researchers published this month in the Journal of Hospital Medicine.

NEW YORK

– May 19, 2015 /Press Release/ ––

The largest urban health systems, which serve as safety nets for large patient populations with lower socioeconomic status and greater likelihood to speak English as a second language, do worse on government patient satisfaction scores than smaller, non-urban hospitals likely to serve white customers with higher education levels, according to a new study by Mount Sinai researchers published this month in the Journal of Hospital Medicine.

Patient satisfaction scores, in part due to the Affordable Care Act of 2010, are a key part of the formula that determines reimbursements levels to hospitals by the Centers for Medicare and Medicaid Services (CMS). The ACA has encouraged hospitals to evolve from a fee-for-service model to one based on measures of value, including patient satisfaction. Hospitals are rewarded or penalized based on metrics that assess quality and efficiency of care in part culled from Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys.

The study authors suggest that the current formulas need adjustment to be fair to large, urban hospitals, and offer a formula to achieve this equity.

“Our analysis found that the lowest satisfaction scores were obtained from population-dense regions of Washington, DC; New York State, California, Maryland and New Jersey, and the best scores were from Louisiana, South Dakota, Iowa, Maine and Vermont,” said senior author Randall Holcombe, MD, Professor, Medicine, Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, and Chief Medical Officer for Cancer for The Mount Sinai Health System.

“Across the country, large hospital size and non-English as a primary language predicted poor patient satisfaction scores while white race and higher education level predicted better scores,” said co-author Daniel McFarland, DO, Clinical Fellow, Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai. “Other demographic factors were also important but these four were the most significant.”

“This study points out that the interpretation of patient satisfaction scores can be very complex,” said Sandra Myerson, MBA, MS, BNS, RN, Senior Vice President and Chief Patient Experience Officer of the Mount Sinai Health System. “It is important to understand these trends in order to provide the highest quality of patient experience.”

Earlier this month, Thomas Greaney explained the antitrust issuescomprehensively in Health Affairs. “Because each market is local, antitrust analysis would also require an assessment of the competitive overlap in each region,” he wrote. Greaney, is the Chester A. Myers Professor of Law and director of the Center for Health Law Studies at Saint Louis University School of Law.

There is no evidence that insurance or provider monopolies are good for consumers, he wrote, citing Boston and Pittsburgh as evidence that big is not necessarily better in health care or health insurance.

For a good review of the regulatory hurdles insurers face, see this thorough analysisi*** in The New York Times by Robert Cyran. Regulators are concerned about how reduced competition may drive up prices, he explained, writing, “Insurance markets are highly concentrated, and big mergers will make them even more so.”

***Excerpt from The New York Times article
“What’s more, the argument that a big merger would create competition for an even heftier rival has already failed in other industries. In 2011, for example, Sprint, the third-largest cellphone service provider at the time, defended its plan to buy T-Mobile US, the fourth-largest, as necessary to keep its rivals Verizon and AT&T in check. The Federal Communications Commission and the Justice Department rejected the contention, making clear that shrinking the market to fewer than two nationwide carriers would harm consumers.”

Insurers could also argue that a combination would create savings and improvements in technology that would redound to consumers’ benefit. Besides, they may point out, state insurance commissioners would have to approve any rise in insurance premiums. Yet the commissioners have often been reluctant to deny insurers rate increases, and insurance company mergers typically lead to higher premiums, according to a study by Leemore Dafny, former director of health care antitrust at the Federal Trade Commission.

So what might persuade the regulators?

The Affordable Care Act could be the answer. President Obama’s health care overhaul creates online exchanges for buying coverage, allowing insurers to expand into new markets without hiring expensive agents. The companies will still need the approval of state commissioners, but the lower barriers to entry should stir more competition – and, at least in the future, appease regulatory fears. It’s unclear whether that would be enough to counterbalance concerns over the top five insurers’ currently chunky market shares.”

The Guide to Clinical Preventive Services presents abridged U.S. Preventive Services Task Force (USPSTF) recommendations on screening, counseling, and preventive medications for use in primary care practice. The 2014 Guide continues the precedent set by earlier editions in providing the Task Force recommendations in a form that provides on-the-job clinical decision support for clinicians. The Guide is organized and cross referenced so that clinicians can search for recommendations alphabetically by topic and by patient category (adult or child/adolescent).

Related Resource

Choosing Wisely is an initiative of the ABIM Foundation that promotes patient-physician conversations about unnecessary medical tests and procedures.

The top five unnecessary tests and treatments have been identified in newborn medicine, according to an article published online July 20 in Pediatrics.

…

These included:
(1) avoiding routine use of antireflux medications for treatment of symptomatic gastroesophageal reflux disease or apnea and desaturation treatment in preterm infants;
(2) for treatment of initially asymptomatic infants without evidence of bacterial infection, routine continuation of antibiotics beyond 48 hours should be avoided;
(3) routine pneumograms for predischarge assessment of ongoing/prolonged apnea of prematurity should be avoided;
(4) in the absence of indication, daily chest radiographs should be avoided for intubated infants; and (5) in preterm infants, routine screening term-equivalent or discharge brain magnetic resonance imaging should be avoided.

“The Choosing Wisely **Top Five for newborn medicine highlights tests and treatments that cannot be adequately justified on the basis of efficacy, safety, or cost,” the authors write. “This list serves as a starting point for quality improvement efforts to optimize both clinical outcomes and resource utilization in newborn care.”

Pharmaceutical experts clued us in on how to get the biggest discounts at the pharmacy counter.

Shop around: A 2013 study by Consumer Reports found that doing a little comparison shopping can have a big payoff, especially if you’re paying out of pocket for your medications. The study found a $749 difference between the highest- and lowest-priced stores when shopping for a month’s supply of five drugs. Costco was the least expensive (and you don’t have to be a member to use its pharmacy), while CVS, Target and Rite Aid were the most expensive.

Be proactive about getting the generic version: Ask if there are generic or less-expensive brand-name drugs that would work just as well as the prescription and over-the-counter medications you’re taking now,” Engle said. “If a generic is not available, check to see if you can use a therapeutic alternative, which is a similar drug that gives the same result that is available as a generic.”

Split pills: Check with your pharmacist to see if your medication is safe to split and — if it is available in a variety of strengths that cost about the same amount.

Extra Help (program thru the US Social Security Administration for limited income people)

NeedyMeds – Non-profit information resource devoted to helping people in need find assistance programs to help them afford their medications and costs related to health care. Includes coverage gap programs.

This is all a mouthful, and it’s striking and a bit misguided from two perspectives. First, this requires health care providers to present material to or interact with patients electronically in the name of patient engagement. But it is really mostly about shoveling uninspiring material at our patients that is redolent of highly technical jargon with minimal context, with the belief that it is somehow good for patients to be engaged in this way. The intent is admirable, but the execution flawed. In addition, it is not surprising that many providers have had challenges meeting the Stage 2 requirement that five percent of patients download their medical records. It seems akin to saying that this week’s book club selection is the text for advanced graduate study of quantum mechanics — and then wondering why no one shows up for the meeting.

Some define engagement in terms of how many times consumers or patients interact with informational websites or portals. Both insurers and providers do this. Once again, there is puzzlement over why consumers would choose to spend more time on sites such as BuzzFeed, Facebook and Yahoo, rather than intently study their health benefits or review their lab tests.

At Partners HealthCare Connected Health, our first generation interest in engagement came when we saw, reproducibly, that people who interact with connected health programs have consistently better health outcomes.

This brings up two salient points: The first is how finely we can measure engagement using connected health.

…One of the intriguing findings of the study was that measures that could be obtained by a simple verbal interview, without physical examination turned out to be the strongest predictors. Simple metrics such as our self-reported health status and our preferred walking pace was highly predictive in both sexes and across different causes of death. In otherwise healthy people, smoking remained the strongest predictor. Unfortunately, cardiorespiratory fitness measurements were not included in the analysis, but based on our own and others research, we think some simple measure of fitness certainly would be among the most important variables.

“Time to Talk Tips” is one of the resources in the “Time to Talk Campaign,” managed by the National Center for Complementary and Integrative Health (NCCIH), at the National Institutes of Health (NIH).

Like any health-related decision, your decision about whether to use complementary health practices is central to your health and safety. Yet, information you find on the Web is not always specific to your illness or based on scientific evidence.

The NIH monthly consumer-friendly series, “Time to Talk Tips,” discusses specific health topics, together with the scientific evidence related to those topics. The series is designed to encourage you and your medical doctors or other healthcare providers to talk about any complementary practice that you are considering.

The series includes simple tips, such as, taking vitamin C regularly does not reduce the likelihood of getting a cold, but may improve some cold symptoms, and some dietary supplements may interact with prescription or over-the-counter medications or other dietary supplements.

A new study led by Shi, chair of the section of oral biology at the UCLA School of Dentistry, describes more precisely the mechanism that makes the mouthwash’s active ingredient so effective.

The research, published in the June issue (PDF) of the Proceedings of the National Academy of Sciences, explains how a specifically targeted antimicrobial peptide, or STAMP, known as C16G2 works to eradicate only the harmful acid-producing Streptococcus mutans bacteria, the main cause of tooth decay, without disturbing the benign and beneficial bacteria in the mouth.

These changes resulted in a microbial community structure that supports better oral health.

The finding is a critical advance because, as scientists have understood for about two decades, the vast majority of bacterial cells in the human mouth are not harmful to our health. Most common broad-spectrum antibiotics and conventional mouthwashes indiscriminately kill both beneficial and harmful pathogenic organisms, and their effects last for only about 12 hours. In addition, overusing broad-spectrum antibiotics can seriously disrupt the body’s ecological balance, which can make people more susceptible to microbial infections. As a result, there is no effective treatment for bacteria-induced tooth decay.

Shi said the STAMP approach would be a unique solution for re-engineering the mouth’s microbiome for long-term health.

C16G2, which is now delivered via a gel tray, is being developed for use in preventing tooth decay and cavities under an investigational new drug application with the U.S. Food and Drug Administration by Los Angeles-based C3 Jian, a company Shi founded around patent rights he developed at UCLA. It is currently in Phase 2 clinical trials.

A new study from researchers at Beth Israel Deaconess Medical Center suggests that risk factors for readmission change significantly over the course of the 30 days following hospital discharge. Thirty-day hospital readmission rates have become a federal quality metric intended to reflect inpatient quality of care and unnecessary health-care utilization.

Published June 2 in the Annals of Internal Medicine, the research suggests that two distinct 8-day and 30-day readmission rates would serve as better inpatient quality measurements and would better inform readmission prevention strategies.

…

he authors also noted that other research has shown that hospitals that strictly follow evidence-based care standards do not necessarily have the lowest readmission rates and that readmission rates do not serve as a benchmark for inpatient mortality. Under the Patient Protection and Affordable Care Act, the Centers for Medicare & Medicaid Services may reduce payments to acute-care hospitals deemed to have excess readmissions within 30 days of discharge.

The study also found that discharges between 8 a.m. and 12:59 p.m. were associated with lower odds of an early readmission. The authors noted that discharge in the first part of the day likely gave patients and their families more time to access community resources such as pharmacies and social supports, thereby reducing the likelihood of readmission.

The authors also found that social determinants of health are closely tied to readmissions, as they affect how patients access care. They evaluated the effect of barriers to health literacy on readmissions and found that they were associated with both early and late readmissions. A patient’s insurance status was also relevant among those readmitted in the late period; patients with unsupplemented Medicare or Medicaid were more likely to be readmitted 8 or more days after discharge.

The authors stressed that both hospital and outpatient settings need systems of care that closely monitor patients as they transition their medical care from the hospital team back to the primary care team. Post-discharge monitoring would better enable a team to make sure patients adhere to the detailed care plan designed by the hospital team, such as taking medications correctly and keeping follow-up appointments.

California and Oregon will be the first states in the nation to allow women to get birth control pills and other hormonal contraceptives directly from their pharmacists – without a doctor’s prescription.

As California officials were busy finalizing regulations on a state law passed in 2013, Oregon’s governor Kate Brown signed a similar bill into law last week.

The two measures were hailed by women’s health advocates. They noted that men have long had an easier time getting birth control, simply purchasing condoms over the counter.

“We support efforts like these that remove barriers to women gaining access to birth control and other reproductive health care,” said Kathy Kneer, President and CEO of Planned Parenthood Affiliates of California, in a written statement.

We made a decision some years ago to build the case for connected health around the management of these illnesses because:

They are costly. By some estimates these chronic diseases account for 70% of U.S. health care costs.

They have a significant lifestyle component. This backdrop seems an ideal canvas for connected health interventions because they involve motivational psychology, self-tracking and engagement with health messages. These chronic illnesses pose a unique challenge in that the lifestyle choices that accelerate them are for the most part pleasurable (another piece of cheese cake? spending Sunday afternoon on the couch watching football, smoking more cigarettes and drinking more beer.) In contrast, the reward for healthy behavior is abstract and distant (a few more minutes of life sometime down the road or an avoided heart attack or stroke). This combination of lack of symptoms and the uphill battle around lifestyle improvement makes these illnesses uniquely challenging.

They are mostly amenable to tracking some objective bit of information about you (e.g. your blood pressure, blood glucose or activity level) in order to make you more aware and, hopefully improve your lifestyle in order to improve your health.

Because these conditions are silent and because most people would rather not be reminded that they have an illness, we found that a strong engagement platform is needed to get people’s attention. We also found that we need to create tools that nudge people to adopt and sustain a healthy lifestyle rather than ignore our natural tendencies to ignore these silent conditions and engage in unhealthy behaviors.

Evidence indicates that for patients undergoing low-risk surgery, routine testing does not improve outcomes and can actually lead to surgical delays, patient anxiety and other issues. The Choosing Wisely campaign, which started in the United States and spread to Canada and other countries, aims to raise awareness of unnecessary tests and procedures among physicians and patients to decrease their use.

…

“Rates of preoperative testing before low-risk procedures were higher than expected, given current guidelines and recommendations, with a significant degree of regional and institutional-level variation across hospitals in a large, diverse jurisdiction with a single-payer health system,” writes Dr. Sacha Bhatia, Department of Cardiology and the Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, with coauthors.

There was a 30-fold difference between institutions with the lowest and highest rates of ordering preoperative tests.

Previous studies have looked at patients over age 65, whereas this study included all patients over age 18.

“Our finding emphasizes the need for re-evaluation of ordering decisions and clinical pathways for patients preparing for low-risk procedures. In particular, preoperative anesthesia and medical consultations have been shown to increase preoperative testing rates.”

The authors suggest more research to understand why these tests continue to be performed, which may be useful for institutions in improving their ordering practices.

May 29, 2015 / B3C newswire / — In the German Center for Infection Research (DZIF), scientists from the universities of Tübingen, Münster and Munich join forces and prepare together with the company Hyglos clinical studies on an active substance against the dreaded hospital pathogen Staphylococcus aureus: A highly effective protein from bacteria-specific viruses, so-called bacteriophages, shall rapidly kill the bacteria, which frequently occur in the nose. Due to the specific action, the natural microflora is maintained. Such prophylactic treatment of nasal colonization could counteract the spread of especially methicillin-resistant staphylococcus aureus (MRSA) in hospitals and thereby prevent infections in patients.

Since President Barack Obama’s State of the Union Address in January 2015, the nation has been talking about a revolution in patient care, known by many as precision medicine.

Of course, the country is used to hearing the president talk about health care, especially the Affordable Care Act. But when the White House starts launching $215 million initiatives to accelerate research—in this case, the Precision Medicine Initiative, according to a White House Press release—you can be sure it’s not just a passing fad.

First, what is precision medicine?

Precision medicine is about tailoring treatments to the patient’s genome and body function. The promise is that this detailed personal health data can determine what’s most effective for each individual, which can lead to better outcomes.

Most of precision medicine’s application currently focuses on cancer. Launched in 2013, Penn Medicine’s Center for Personalized Diagnostics (CPD) helps oncologists determine the best treatment for their cancer patients by looking at the cancer’s genome.Here’s how precision medicine is being practiced at Penn:

A patient is diagnosed with cancer.

If the cancer involves a solid tumor—like breast, lung, or colon cancer—the tumor is surgically removed during a biopsy, and a chunk of the tissue is sent to Penn Medicine’s CPD. If the cancer involves blood or bone marrow—like leukemia—a sample of the blood or bone marrow is sent.

The CPD sequences a panel of genes that are known to be involved in cancer. This test examines DNA within the tumor, blood or bone marrow sample. The goal is to find DNA mutations that are driving the cancer.

A report on the mutations found is sent to the patient’s oncologist.

The oncologist determines if there are therapies or treatments available that work better than others—or not at all—on the patient’s particular type of cancer.

“We’re using precision medicine to give patients the right drugs, guided by the DNA sequence information from their cancer, so we’re not exposing them to potentially toxic effects,” explains David Roth, MD, PhD, director of the CPD. “This individualized therapy is better than treatment based on the ‘average patient.’”

Precision Medicine is being researched, translated and applied across Penn Medicine. Here,
experts from the Center for Personalized Diagnostics share four predictions on how precision medicine will change how cancer is treated in future generations.

1. Cancer will be diagnosed earlier.

Jennifer Morrissette, PhD, clinical director of the CPD:

“There are different stages of tumors. The earlier you catch the tumor, the more likely you are to survive it. My theory is that this century will be the century of diagnostics. We will be diagnosing people’s cancers earlier and earlier.

“That way, we are not dealing with advanced metastatic tumors that have acquired so many different changes that they’re hard to treat. We’ll be capturing tumors very early, in stage one; have a definitive surgery; follow the patient for a certain number of years to make sure that the cancer hasn’t spread; and then they’ll be cured.

“Some people put off seeing a physician because they don’t want chemo, but the longer they put it off, the more likely they are going to have metastatic disease.”

2. Cancer treatment will be based on each person’s health profile.

“[In the past,] doctors had been treating [the average patient] based upon results from a large study.

“The revolution in precision medicine is that now we have better tools to understand what’s going on with you as an individual. Instead of saying, ‘Okay, you have this particular cancer, and you have a 30 percent chance. So, go ahead and get this toxic therapy,’ we can be much more specific.

“If we were able to tell you that you have a five percent chance of responding to a chemotherapy based on the makeup of your tumor, would you still do it?”

3. Gene paneling will be used for diagnosis, not just treatment.

David Lieberman, MS, CGC (certified genetic counselor):

“We tend to see certain genes mutated in certain cancers. For example, there is a certain set of
genes [that are] typically mutated in lung cancer or another set in lymphoma.

“It is not always clear using historical methods what type of cancer a patient has. This makes treatment decisions challenging. Sequencing the tumor’s DNA on a panel of known cancer-related genes may help clarify the cancer’s origin and, in this way, assist the clinician in determining treatment or prognosis.”

$215 million: The amount the White House will invest in the Precision Medicine Initiative in 2016
Source: WhiteHouse.gov

4. More cancer patients will have a treatment team, rather than just an oncologist.

Jennifer Morrissette PhD, clinical director of the CPD:

“It’s not going to be one physician making all the decisions. Cancer treatment has gotten much more complex. Because of the availability of multi-gene testing, you need a group of people with different types of expertise to make the best decision for a patient.

“In addition to the team directing care for the appropriate approach—whether it’s surgery, radiation, chemotherapy, pain management—now there is also the genetic component.

“[The team’s] able to sit in a room with people from the lab who can talk about what the result means, have the oncologist tell them about the patient and then get the clinical geneticist’s notion that there may be an inherited predisposition. Then, they walk out with a consolidated treatment plan for that patient.”

The future of medicine

For more than 250 years, advancements like “precision medicine” have been the hallmark of Penn Medicine. As the first school of medicine in the United States, it has been and continues to be a place where the future of medicine and the future leaders in medicine are being developed.

A guide to weighing up the benefits and harms of health screening programmes

Public expectations about screening don’t match what screening programmes can deliver. By addressing misconceptions about how screening works, its limitations and the calculation of benefits and harms, scientists and clinicians hope to bridge the gap between the active debates of the scientific community and the concerns raised by the public.

Mature doctor talking to his patient who is about to receive an MRI Scan.url=http://www.istockphoto.com/search/lightbox/9786662][img]http://dl.dropbox.com/u/40117171/medicine.jpg[/img][/url]

From the 14 July 2015 mHealth post

The following is a guest contributed post by Karen Holzberger, Vice President and General Manager for Diagnostics at Nuance.

The Joint Commission standards for diagnostic imaging, which recently went into effect, are designed to help prevent duplicate and unnecessary medical imaging of patients, and reduce potentially harmful exposure to radiation when patients need CT scans, MRI or a combination of these and other diagnostic tests. Beginning July 1, 2015, these standards require protocols, documentation and data collection, staff education and other criteria that raise the bar for quality and safety at ambulatory imaging sites, critical access hospitals and accredited hospitals. What do these standards really mean to the patient?

The new imaging standards focus primarily on the radiation dose index. There are a number of uncertainties tied to the long-term impact of imaging on patients, but researchers agree it impact patients differently depending upon sensitivities to radiation, age, body parts being tested, absorption rates and other factors and these are still being studied. In the meantime, to prevent undue risk, The Joint Commission has put a stake in the ground with these specific standards to help improve patient safety. The Joint Commission joins other accredited healthcare organizations, such as the American College of Radiology (ACR) and other clinical associations that are releasing new quality-focused recommendations,enhanced education tools and technologies to make it easier for healthcare teams to keep you safe from unintended risks while you receive diagnostic imaging that could shed light on serious health conditions.

ancer, all by itself, is bad enough. Although cancer treatment, especially chemotherapy, has become much gentler than it was a decade ago, most interventions still carry significant risks and side effects.

Recently, many physicians have focused on a different sort of hazard that they call “financial toxicity.” Along with the distress of a cancer diagnosis and the discomforts of treatment, patients increasingly have to deal with the cost, anxiety and loss of confidence inspired by large, unpredictable expenses, often compounded by decreased ability to work.

A team led by Jonas de Souza, MD, a head-and-neck cancer specialist at the University of Chicago Medicine, has developed the first patient-oriented website devoted to helping cancer patients understand and cope with financial toxicity (FT). Their goal is to increase awareness of this side effect prior to and during medical treatment so patients know what to expect and can better understand how costs impact them and their families.

Abstract

New estimates from the Commonwealth Fund Biennial Health Insurance Survey, 2014, indicate that 23 percent of 19-to-64-year-old adults who were insured all year—or 31 million people—had such high out-of-pocket costs or deductibles relative to their incomes that they were underinsured. These estimates are statistically unchanged from 2010 and 2012, but nearly double those found in 2003 when the measure was first introduced in the survey. The share of continuously insured adults with high deductibles has tripled, rising from 3 percent in 2003 to 11 percent in 2014. Half (51%) of underinsured adults reported problems with medical bills or debt and more than two of five (44%) reported not getting needed care because of cost. Among adults who were paying off medical bills, half of underinsured adults and 41 percent of privately insured adults with high deductibles had debt loads of $4,000 or more.

BACKGROUND

The Affordable Care Act has transformed the health insurance options available to Americans who lack health benefits through a job. Numerous surveys have indicated that the law’s coverage expansions and protections have reduced the number of uninsured adults by as many as 17 million people.1

But Congress intended the Affordable Care Act to do more than expand access to insurance; it intended for the new coverage to allow people to get needed health care at an affordable cost. Accordingly, for marketplace plans, the law includes requirements like an essential health benefit package, cost-sharing subsidies for lower-income families, and out-of-pocket cost limits.2 For people covered by Medicaid, there is little or no cost-sharing in most states.

But most Americans—more than 150 million people—get their health insurance through employers.3 Prior to the Affordable Care Act, employer coverage was generally far more comprehensive than individual market coverage.4 However, premium cost pressures over the past decade have led companies to share increasing amounts of their health costs with workers, particularly in the form of higher deductibles.5

In this issue brief, we use a measure of “underinsurance” from the Commonwealth Fund’s Biennial Health Insurance Survey to examine trends from 2003 to 2014, focusing on how well health insurance protects people from medical costs. Adults in the survey are defined as underinsured if they had health insurance continuously for the proceeding 12 months but still had out-of-pocket costs or deductibles that were high relative to their incomes (see Box #1). The survey was fielded between July and December 2014. This means that we could not separately assess the effects of the Affordable Care Act on underinsurance because people who were insured all year in the survey had insurance that began before the law’s major coverage expansions and reforms went into effect. People who had new marketplace or Medicaid coverage under the Affordable Care Act would not have had that coverage for a full 12 months, as it would have begun in January 2014 at the earliest. Similarly, people with individual market coverage who were insured all year would have spent all or part of the period in plans that did not yet reflect the consumer protections in the law.6

Health care that costs more than it needs to is not just an annoyance; it’s a big factor in income inequality in the United States. The financial, physical and emotional burden of disease are major drivers of poverty. At the same time, the high cost of health care even after the Affordable Care Act means that many people don’t access it when they need it, and this in turn deprives large swathes of the population of their true economic potential as entrepreneurs, workers and consumers. People who are burdened by disease and mental illness don’t start businesses; don’t show up for work; and don’t spend as much money on cars, smartphones and cool apartments. Unnecessary sickness is a burden to the whole economy.

How did we get this way? What was the mechanism that differentiated U.S. health care from all other advanced countries? The usual suspects (such as “We have the most sophisticated research and teaching hospitals,” or “It’s the for-profit health insurers” or “Doctors make too much”) all fail when we compare the United States with other sophisticated national systems such as those in Germany and France. Other countries have all of these factors in varying amounts — private health insurers, world-class research, well-paid physicians — and cost a lot, but still spend a far smaller chunk of their economy on health care. Blame has been leveled in every direction, but in reality no single part of health care has been the driver. The whole system has become drastically more expensive over the last three decades.

What’s the Mechanism?

Since the difference between the United States and other countries is so large and obvious, there should be some way we can look at health care spending that would make that mechanism jump out at us. And there is a way.

…

That first big leap is between 1982 and 1983. What was different in 1983 that was not there in 1982? DRGs, diagnosis-related groups — the first attempt by the government to control health care costs by attaching a code to each item, each type of case, each test or procedure, and assigning a price it would pay in each of the hundreds of markets across the country. The rises continue across subsequent years as versions of this code-based reimbursement system expand it from Medicare and Medicaid to private payers, from inpatient to ambulatory care, from hospitals to physician groups and clinics, to devices and supplies, eventually becoming the default system for paying for nearly all of U.S. health care: code-driven fee-for-service reimbursements.

Cost Control Drives Costs Up?

How can a cost control scheme drive costs up? In a number of ways: In an attempt to control the costs of the system, the DRG rubric controlled the costs of units, from individual items like an aspirin or an arm sling to the most comprehensive items such as an operation or procedure. The system did not pay for an entire clinical case across the continuum of care from diagnosis through rehab; or for an entire patient per year on a capitated basis, which would capture the economic advantages of prevention; or for an entire population. While it is more cost-effective (as well as better medicine) to provide a diabetes patient with medical management, in-home nursing visits and nutritional counseling rather than, say, waiting until the patient needs an amputation, the coding system actually punished that efficiency and effectiveness. Under this system, we got paid for our inefficiencies, and even for our mistakes: Do-overs would often drop far more to the bottom line than the original procedure did.

The system punished, rather than rewarded, spending more time with patients, trying to help patients before their problems became acute, or maintaining a long-term, trusted relationship with patients. Under a code-driven fee-for-service system, getting serious about prevention and population health management would be a broad road to bankruptcy.

If extra items were deemed necessary (an extra test or scan, say), there were codes for that, and reimbursements awaiting. In so doing, the system rewarded doing more (“volume”) rather than whatever would be the best, most appropriate, most efficient treatment path (“value”). It provided a written, detailed catalog of reimbursements which rewarded diagnoses of greater complexity, rewarded new techniques and technologies with new and usually higher reimbursements, and especially rewarded systems that invested in a greater capability to navigate the coding system. At the same time, the reimbursements were constantly open to pressure from the industry. Each part of the industry, each region, each specialty, each part of the device industry, became fiercely focused on keeping those reimbursements up, and getting new codes for more costly procedures.

The business and strategic side of health care became a matter of making money by farming the coding system. Do more of what gets better reimbursement, less of what does not. Make sure every item gets a code and gets charged for. The codes became a manual for success, a handbook for empire.

The Smoking Gun

The smoking gun is right there in the chart, at the big split between the trajectories of the United States and other countries. And today, at this moment, the code-based fee-for-service payment system is still by far the basis of the majority of all revenue streams across health care.

The unifying factor between multiple new strategies unfolding in health care right now, including patient-centered medical homes, pay for performance, bundled prices, reference prices, accountable care organizations, direct pay primary care and others, is to find some way around the strict code-based fee-for-service system, either by avoiding it entirely or by adding epicycles and feedback loops to it to counter its most deleterious effects.

There is no perfect way to pay for health care. All payment methods have their drawbacks and unintended consequences. But the code-based fee-for-service system got us here, and any path out of the cost mess we are in has to get us off that escalator one way or another.

I believe the concept of value-based care is good for healthcare. VBC encourages providers to make changes that put the patient at the center of care, so that different services can be provided across providers in a collaborative way. If all went according to the VBC vision, there would be fewer redundant tests, more emphasis on preventative care, and an effort to keep high-risk patients out of the emergency room. It’s also better for costs, something we desperately need in the US, where healthcare spending per capita is more than twice the OECD average.

But Lisa’s story, at the leading edge of the value-based experiment, is not good at all. ACOs and most other value-based models are new, constantly changing, and unproven. ACOs report on 33 metrics that are supposed to represent the quality of care provided by their networks of providers. While still extremely limited in scope, any more than 33 metrics would have made Lisa’s job impossible. So far, few ACOs have reported any savings. Worse — the metrics are unproven. What if they overemphasize standardized process over patient outcomes? And what if efficiency measures result in neglectful and impersonal care? A lot is riding on Lisa’s testing ground.

The administrative challenge

By engaging with and learning from people like Lisa, I have begun to understand the problems frontier administrators face — the same problems countless others will face if we don’t address the administrative burden early on. Here are a few of the top headaches being rolled out in the name of value:

Selecting metrics

For ACOs, 33 metrics are tracked today. Inevitably, these will expand and change as accountable care evolves. There are also countless other systems of metrics encouraged by other incentive programs: the Physician Quality Reporting System measures, Meaningful Use metrics, Agency for Healthcare Research and Quality Indicators, the Consumer Assessment of Healthcare Providers and Systems for patient experience metrics, indicators for each specialty (Stroke and Stroke Rehabilitation Physician Performance Measurement Set, Endoscopy and Polyp Surveillance Physician Performance Measurement Set, and the Heart Failure Performance Measurement Set, to name a few). The document outlining protocols for the Physician Quality Reporting System is 18 pages long, with a mouthful of a title to match: “The 2015 Physician Quality Reporting System (PQRS) Measure-Applicability Validation (MAV) Process for Claims-Based Reporting of Individual Measures.” Got that? A new piece of legislation that passed the House of Representatives last week — the “doc fix” bill — is about to revamp many of these requirements once again.

Collecting data

Lisa had to fumble through different electronic systems and paper charts to extract the relevant data for each patient in her panel at dozens of different clinics. In many cases, it was clear that care had been provided (e.g. an unstable patient had been upgraded from a cane to a walker), but the documentation wasn’t there (to fulfill the “Screening for Future Fall Risk” metric, documentation must state whether the patient had no falls, one fall without major injury, two or more falls, or any fall with major injury.) Therefore, even though care was provided to prevent future falls, the documentation did not meet the CMS requirement and no credit was given.

For the next reporting year, Lisa is designing her own reporting mechanisms for clinics and doctors. She says that her first reporting experience “was invaluable in learning ways to improve the reporting for year 2015 and beyond,” and she is putting processes in place to facilitate reporting next year. But each clinic is different: some need a page at the front of their paper chart with check boxes, and some have templates in their electronic health records. Her new processes may improve the situation, but additional tracking could also cut into time doctors spend with patients and add to the squeeze they already feel.

Integrating data

Lisa integrated all the data from each clinic manually, and this is a problem for small institutions who are trying to communicate and coordinate with each other. Right now it takes a long time and is not very scalable. Even at larger institutions with leading electronic health record systems, the data is locked away within proprietary databases, often in incompatible formats. Clinical data is rarely integrated with financial and patient-reported data in the way required to tie outcomes and claims to reimbursements in a value-based model.

Reporting

After all of her data collection, Lisa still had to submit her data to a third part to produce reports, and she will wait many months for the results. The CMS websites are comically complex ; the instruction manual for using the CMS metric reporting interface is 127 pages long.

Putting patients at the center

If these problems aren’t addressed, we’re in for a long and painful healthcare reform. Administrative costs will continue to rise, along with another generation of frustrated physicians and admins. Moreover, value-based care could be deemed a failure not because it’s a bad idea but because of poor implementation. Instead of putting patients at the center of care, it could breed more bureaucracy and force doctors to spend more time reporting on metrics and less time with patients.

We can address these issues and we must — to give value-based care a chance at moving the US toward more patient-centered, less exorbitant healthcare.

A few days ago, we wrote an editorial for US News and World Reports on the scant or dubious evidence used to support some healthcare policies (the editorial is reproduced in full below).In that case, we focused on studies and CMS statements about a select group of Accountable Care Organizations and their cost savings. Our larger point however is about the need to reconsider the evidence we use for all healthcare-related decisions and policies. We argue that an understanding of research design and the realities of measurement in complex settings should make us both skeptical and humbled.Let’s focus on two consistent distortions.

Evidence-based Medicine (EBM). Few are opposed to evidence-based medicine.What’s the alternative? Ignorance-based medicine? Hunches?However, the real world applicability of evidence-based medicine (EBM) is frequently overstated. Our ideal research model is the randomized controlled trial, where studies are conducted with carefully selected samples of patients to observe the effects of the medicine or treatment without additional interference from other conditions. Unfortunately, this model differs from actual medical practice because hospitals and doctors’ waiting rooms are full of elderly patients suffering from several co-morbidities and taking about12 to 14 medications, (some unknown to us). It is often a great leap to apply findings from a study under “ideal conditions” to the fragile patient. So wise physicians balance the “scientific findings” with the several vulnerabilities and other factors of real patients.Clinicians are obliged to constantly deal with these messy tradeoffs, and the utility of evidence-based findings is mitigated by the complex challenges of the sick patients, multiple medications taken, and massive unknowns. This mix of research with the messy reality of medical and hospital practice means that evidence, even if available, is often not fully applicable.

Relative vs. Absolute Drug Efficacy:

Let’s talk a tiny bit about arithmetic. Say we have a medication (calledX) that works satisfactorily for 16 out of a hundred cases, i.e., 16% of the time.Not great, but not atypical of many medications.Say then that another drug company has another medication (called “Newbe”) that works satisfactorily 19% of the time. Not a dramatic improvement, but a tad more helpful (ignoring how well it works, how much it costs, and if there are worse side effects).But what does the advertisement for drug “Newbe” say? That “Newbe” is almost 20% better than drug “X.” Honest. And it’s not a total lie.Three percent (the difference between 16% and 19%) is 18.75%, close enough to 20% to make the claim legit. Now, if “Newbe” were advertised as 3% better (but a lot more expensive) sales would probably not skyrocket. But at close to 20% better, who could resist?

Policy:So what does this have to do with healthcare policy?We also want evidence of efficacy with healthcare policies but it turns out that evaluation of these interventions and policies is often harder to do well than are studies of drugs. Interventions and policies are introduced into messy pluralistic systems, with imprecise measures of quality and costs, with sick and not-so-sick patients, with differing resources and populations, with a range of payment systems, and so on and so on. Sometimes, randomized controlled trials are impossible.But sometimes they are possible but difficult to effect. Nevertheless, we argue they are usually worth the effort. Considering the billions or trillions of dollars involved in some policies (e.g., Medicare changes, insurance rules) the cost is comparatively trivial.

But there’s another question: What if a decent research design is used to measure the effects of a large policy in a select population but all you get is a tiny “effect?”What do we know? What should policymakers do? Here’s what we wrote in our recent editorial in the US News and World Report….

Study finds doctors must make great effort to provide patients more useful information to help them make medical choices

Patients faced with a choice of surgical options want to engage their physicians and take a more active role in decision-making, according to a study (abstract 567) released at Digestive Disease Week® (DDW) 2015. Further, those physicians must provide better support tools to help patients participate in the decision-making process. The study found that patients consult multiple sources (Internet, family, friends, doctors, etc.) and say that while doctors provide the most believable information, it was also the least helpful.

New research finds that misdiagnoses lead to increased risk of incorrect antibiotic use, threatening patient outcomes and antimicrobial efficacy, while increasing healthcare costs. The study was published online today in Infection Control & Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America.

“Antibiotic therapies are used for approximately 56 percent of inpatients in U.S. hospitals, but are found to be inappropriate in nearly half of these cases, and many of these failures are connected with inaccurate diagnoses,” said Greg Filice, MD, lead author of the study. “The findings suggest that antimicrobial stewardship programs could be more impactful if they were designed to help providers make accurate initial diagnoses and to know when antibiotics can be safely withheld.”

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Additionally, researchers found that overall, only 58 percent of patients received a correct diagnosis, indicating that diagnostic errors were more prevalent in this study than in previous studies unrelated to antimicrobial use. The most common incorrect diagnoses identified by researchers were pneumonia, cystitis, urinary tract infections, kidney infections and urosepsis.

Contributing factors which the researchers said may lead to inaccurate diagnosis and inappropriate antibiotic use include:

Healthcare workers (HCWs) relying on intuitive processes, instead of analytical processes which are more reliable, safe and effective.

The Fifth Annual Benchmark Study on Privacy and Security of Healthcare Data by the Ponemon Institute, sponsored by ID Experts, reveals a shift in the root cause of data breaches from accidental to intentional. Criminal attacks are up 125% compared to five years ago replacing lost laptops as the leading threat. The study also found most organizations are unprepared to address new threats and lack adequate resources to protect patient data. Download the study to learn more.

Patient dumping, or when a hospital discharges a homeless patient to Skid Row or onto the street, has become rare, but still does occur. With so many homeless people who require medical care, hospitals in Los Angeles and across the nation are trying to find ways to help the homeless recuperate after being discharged. There are programs in Los Angeles, but they still are few and far between. Jonathan Lopez, who is a former homeless navigator, has helped many. Many more like him are needed. From my story (Daily News, October, 2013):

Evidence-based medicine has been called “cookbook medicine” by some of its more vocal critics. This implies that evil faceless organisations like Cochrane aim to turn all healthcare workers into mindless automatons who blindly follow dictums derived solely from scientific evidence. I hope it doesn’t surprise many in that this has never been the aim of Cochrane, or EBM in general, nor will it ever be. EBM, or EBP if you prefer the term ‘practice’ rather than the more vague ‘medicine’, is a belief system that rests on three pillars (cf. five in Islam). The EBM pillars are: 1) best available scientific evidence (i.e. the purview of Cochrane and yours truly), 2) clinical experience and 3) patient preferences and values. So, the main gist is that evidence doesn’t matter – no matter how scientific – if we don’t have a clinician at hand to interpret it for the benefit of a particular patient equipped with a particular set of values. For example, in a situation where two very similar patients have the same condition, one might wish to achieve speedy return to work whereas the other might rather avoid pain at all cost. The clinician would then use his or her judgment to identify the best course of treatment for both based on experience and what us science types have to offer. However, let us now leave the two pillars of clinical experience and patient preferences to be explored in future posts so that we can chew the first a bit more.

Now, the evidence bit in EBM is often understood to mean results of systematic reviews(a fancy type of research). Inasmuch as they offer an abstracted truth devoid of context (see my earlier post on mathematical ghosts) they still need to be interpreted for use in particular circumstances. This doesn’t always have to be done for every single patient by every single clinician separately. Think of the usefulness of reinventing the wheel for every drive. Often the thinking behind the interpretation and application of evidence can be written down and made use of by many. On a population level this means drafting guidelines. However, it is important to note that when scientific evidence is freely available one does not need to wait for formal committees to grow their beards long enough to formulate official guidelines. Especially when even supposedly professional guideline developers can do a really poor job (see previous post by Margot Joosen). In fact, all informed people and communities should participate in making sense of and advocating for the use of research to back up health decisions. In the end it affects the quality of care they receive.

Information about the quality and performance of health care facilities can be confusing to consumers. Dozens of government organizations, trade groups and websites rate doctors, hospitals and long-term care facilities on all kinds of scales, from patient satisfaction to medical outcomes.

In 2008, the Centers for Medicare and Medicaid Services (CMS) attempted to simplify some of this data by creating a five-star rating system for nursing homes. The idea was that public reporting would drive improvement in care, helping nursing home residents and their families choose higher quality facilities, in turn encouraging nursing homes to improve quality to retain residents.

This data can be of limited use, however, for people whose decisions are constrained by insurance networks, cost and geography. People who are enrolled in both Medicare and Medicaid, often called “dual eligibles,” are particularly limited in their choices for long-term care. They are much more likely to have lower incomes, disabilities or cognitive impairment, and to receive low-quality health care in poor neighborhoods than other Medicare beneficiaries.

A new study in the May issue of Health Affairs by public health researchers from the University of Chicago, Harvard, and Penn confirms that despite best intentions, the new rating system exacerbated health disparities between this dual eligible group and non-dual eligible nursing home residents, i.e. those with better financial support. By 2010, two years after the system began, both groups lived in higher quality nursing homes overall, but non-dual eligible residents were more likely to actively choose a higher-rated nursing home. The gap between the two groups also increased: dual eligibles were still more likely to live in a one-star home, and less likely than non-dual eligibles to live in a top-rated home.

Members of a panel at Health Journalism 2015 on medical device coverage provided a variety of advice for reporters covering and of the implants, instruments and diagnostic tools common to the modern medical machine.

Moderator of the session was Chad Terhune, aLos Angeles Times reporter who recently found himself chasing an outbreak of carbapenem-resistant enterobacteriaceae (CRE) linked to dirty duodenoscopes. Contributing to the discussion were panelists USA Today investigative reporterPeter Eisler and Scott Lucas, associate director of accident and forensic investigation at the ECRI Institute.

A recent CRE outbreak at Ronald Reagan UCLA Medical Center illustrates the broader issues of medical device approval and oversight. The Olympus scopes used at the Los Angeles hospital, and at other facilities around the nation where the superbug infected patients, did not require any formal study or approval from the FDA before hitting the market because they were considered “substantially equivalent” to a previous models. Equivalency, Eisler explained, allows thousands of devices to move from labs to patients with little more than a short 510K statement that the manufacturer files with the FDA.

Only 10 percent of devices, such as those which “sustain or support life, are implanted, or present potential unreasonable risk of illness or injury” fall into the FDA’s “premarket approval’” category requiring a greater level of regulatory scrutiny, including safety and effectiveness studies, before sale.

Things are not much better once devices hit the market.

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It is important to understand that medical devices seldom stand alone, he said. They are usually part of much broader systems used to deliver care safely to patients. When a patient dies after a ventilator fails, for example, it may be that alarms, communications networks or staffing protocols designed to quickly detect and report the failure did not work.

Thus, if reporters want to understand what went wrong in a specific incident, they should ask about more than the device itself. “The system approach to an investigation is key to finding the answer,” Lucas said.

Also be aware that hospitals are supposed to have detailed plans that tell employees what to do when there is a problem with a device. Sequestering machines that malfunction, and downloading data from them before it is purged, are examples of best-practice steps that reporters can ask about.

Handling the pitch

So what should a reporter do when he or she receives a glowing pitch from a local hospital about the latest device?

Terhune suggests starting with Medicare’s open payments database to see if the doctors involved have a financial interest in the device that’s being pitched. While a financial interest is not necessarily a deal breaker for coverage, it is something reporters should know about going in and make sure they can adequately address in their coverage.

When writing about transparency in health care prices and quality, journalists should expose the myths that health care providers promote. That’s the advice Francois de Brantes gave during a session on price and quality transparency at Health Journalism 2015 last month.

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Providers promote the false ideas that gathering accurate price and quality data is difficult, if not impossible, and that variations in price result from the severity of illness in populations, de Brantes explained. By debunking these myths, journalists would inform policymakers and the public that there are ways to calculate the prices of medical episodes of care accurately, and that price variation can be controlled. “Price varies because of the way physicians practice,” he said.

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Among those myths:

Price is a trade secret

Disclosing prices would impede the ability of health plans, hospitals and physicians to compete effectively

1. Always ask “why?” This seems obvious, but even in this modern era, many patients take it as an article of faith that a doctor’s recommendation is thoughtful and well informed. It may well be; but on any given occasion, it could also be a knee-jerk — born of prevailing tendencies, distractions, and want of time. The question “why” is easily addressed by those who have already thought it over; and is a necessary reality check for those of us who have not.

2. Always ask “what else?” In the case of the fluoroquinolone syndrome, it’s bad enough when a fluoroquinolone was a genuinely thoughtful, warranted choice. It’s downright tragic when a much-less-potentially-toxic, narrow spectrum antibiotic would have served at least as well. “What else?” is a reminder that there is generally more than one way to test or treat, and the one we want is the BEST of them: most likely to help, least likely to hurt. It prods our providers to do the extra work of getting us there when we remind them we want to know the options, and comparison shop them.

3. Always ask “then what?” This would certainly defend against a screening colonoscopy in an 85 year old with congestive heart failure. If I have this test, then what? The answer would have to be: We can find potential cancer early, and fix it now so it doesn’t cause you trouble in ten years. That would invite all concerned to revisit the relevance of that “help” ten years in the future of someone exceedingly unlikely to live that long.

Today, the U.S. Food and Drug Administration launched the agency’s first mobile application (app) specifically designed to speed public access to valuable information about drug shortages.

The app identifies current drug shortages, resolved shortages and discontinuations of drug products.

Drugs in short supply can delay or deny needed care for patients. Drug shortages may also lead health care professionals to rely on alternative drug products, which may be less effective or associated with higher risks than the drug in shortage.

“The FDA understands that health care professionals and pharmacists need real-time information about drug shortages to make treatment decisions,” said Valerie Jensen, associate director of the Drug Shortage Staff in the FDA’s Center for Drug Evaluation and Research. “The new mobile app is an innovative tool that will offer easier and faster access to important drug shortage information.”

App users can search or browse by a drug’s generic name or active ingredient, and browse by therapeutic category. The app can also be used to report a suspected drug shortage or supply issue to the FDA.

The FDA, an agency within the U.S. Department of Health and Human Services, protects the public health by assuring the safety, effectiveness, and security of human and veterinary drugs, vaccines and other biological products for human use, and medical devices. The agency also is responsible for the safety and security of our nation’s food supply, cosmetics, dietary supplements, products that give off electronic radiation, and for regulating tobacco products.

Open the medicine cabinet of a senior and you’re likely to find scores of pill bottles. Physicians are often unaware of all the medications a patient is taking, which can result in unnecessary additional prescriptions, non-prescription medications and potential drug-drug interactions that cause unexpected adverse effects. When a cancer diagnosis is thrown into the mix, the drug-drug interactions can become even more complex. A new study evaluates the currently available screening tools for determining if and when seniors with cancer are taking too many medications and finds that a more comprehensive medication assessment and monitoring plan is needed to improve treatment for this population.

Coordinated care refers to the ability for physicians in different specialties to come together and share skills and accountability for a given patient’s care. Treatment models such as the accountable care organization and patient-centered medical home are operational examples of the trend of coordinated care come to life through a team of clinicians, though more hospitals are starting to see the value in combining disparate care settings in one package.

In fact, two hospitals in New York and New Jersey have taken the concepts of coordinated care and translated those into new physical spaces in their facilities that make it easier for physicians to provide prompt and accurate care. While one focused on health literacy and the other preferred to add new technologies to their hospitals, both represent a significant conceptual step in transforming the physical space of hospitals into embodiments of modern medicine.

1. The $8 million operating room
At first glance, constructing a single room in a hospital for $8 million seems like a gross over-expenditure of funds that could better be spent elsewhere, especially in an industry already facing out-of-control costs. However, CNY Central reported that Crouse Hospital in Syracuse, New York added not just one, but two state-of-the-art operating rooms each with similar price tags.

So what makes these operating rooms so expensive? Thanks to the inclusion of both surgical and radiological equipment, physicians can give patients X-rays and perform surgery without wasting time shuttling all over the facility. According to Adham Kamel, M.D., a surgeon at Crouse Hospital, the new rooms will make it much easier to diagnose and treat stroke victims.

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2. Engaging patients through design
Within the realm of patient engagement, the hospital has always been a nebulous area for patient education and engagement. Some patients simply do not feel comfortable in these facilities, and physicians are often too busy to sit down with their patients and talk them through their conditions for hours on end.

However, officials at New Jersey’s Morristown Medical Center have taken cues from both the physician’s and the patient’s world to create HealtheConnect, a cafe-style lounge room where patients can get help setting up health management apps on their smartphones, tablets or other mobile devices, PFSK.com reported. HealtheConnect took design cues from Apple’s Genius bars to create a welcoming atmosphere for even the most anxious patients.

March 26, 2015 — Researchers atColumbia University’s Mailman School of Public Health analyzed the results of the Oregon Health Experiment, where eligible uninsured individuals were randomly assigned Medicaid or to stay with their current care. Considered controversial because the experiment found no measurable gains for physical health it did reveal benefits for mental health, financial wellbeing, and preventive screening. In terms of quality-adjusted life years, the researchers showed that Medicaid is an excellent value—a $62,000 gain in quality-adjusted life years. Study findings are online in the American Journal of Public Health.
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Summary:The lesbian, gay, bisexual, transgender/transsexual, queer/questioning and intersex (LGBTQI) population has been largely understudied by the medical community. Researchers found that the LGBTQI community experience health disparities due to reduced access to health care and health insurance, coupled with being at an elevated risk for multiple types of cancer when compared to non-LGBTQI populations.

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The study highlights that LGBTQI populations face barriers to health insurance such as when partnerships and marriages are not legally recognized; concerns about disclosure in a health care setting, discrimination, misconceptions, legal and financial barriers and the disenfranchised stress and distress of caregiving same-sex partners.

Additionally, there are higher rates of smoking and substance abuse and low screening rates resulting in poor patient outcomes and survival rates for LGBTQI populations. Her review, The Importance of disclosure: Lesbian, gay, bisexual, transgendered, queer/questioning, and intersex individuals and the cancer continuum, was published in the American Cancer Society’s journal, Cancer.

Researchers identified that the real or perceived limited access to care due to fear of discrimination and lack of sensitivity and knowledge of LGBTQI issues stood as roadblocks to patient care. In a study of family physicians only 1 in 80 reported routinely asking patients about sexual orientation, while the majority reported rarely or never asking. The National Institutes of Health and the Institute of Medicine now recognize gender identify and sexual orientation as vital aspects of a health history and the need for improved research in this population.

“For many years, physicians did not ask patients about their sexual orientation. The importance of recognizing gender identity and sexual orientation is critical to ensuring the best quality and evidence-based care is available to patients,” explained Quinn.

Bacteria that cause many hospital-associated infections are ready to quickly share genes that allow them to resist powerful antibiotics. The illustration, based on electron micrographs and created by the Centers for Disease Control and Prevention, shows one of these antibiotic-resistant bacteria. Credit: CDC/James Archer

Antibiotic resistance is poised to spread globally among bacteria frequently implicated in respiratory and urinary infections in hospital settings, according to new research at Washington University School of Medicine in St. Louis.

The study shows that two genes that confer resistance against a particularly strong class of antibiotics can be shared easily among a family of bacteria responsible for a significant portion of hospital-associated infections.

Drug-resistant germs in the same family of bacteria recently infected several patients at two Los Angeles hospitals. The infections have been linked to medical scopes believed to have been contaminated with bacteria that can resist carbapenems, potent antibiotics that are supposed to be used only in gravely ill patients or those infected by resistant bacteria.

“Carbapenems are one of our last resorts for treating bacterial infections, what we use when nothing else works,” said senior author Gautam Dantas, PhD, associate professor of pathology and immunology. “Given what we know now, I don’t think it’s overstating the case to say that for certain types of infections, we may be looking at the start of the post-antibiotic era, a time when most of the antibiotics we rely on to treat bacterial infections are no longer effective.”

Summary:Cancer patients over the age of 65 often take multiple drugs, which can interfere with cancer treatment. A new study shows that currently used tools to prevent over-medicating senior cancer patients need improvement.

Achieving better health outcomes at a lower cost and succeeding with payment reforms that shift from volume to value is difficult without health information technology (IT). Health IT can engage and support health care providers, patients, and consumers with access to timely and accurate clinical information from electronic health records (EHRs) and other sources. It can also provide access to cost and coverage information that avoids burdensome administrative processes and unexpected costs. Health IT can achieve these benefits through interoperability across information and data exchange platforms – avoiding duplicative parallel systems and additional data entry. Engaged patients and providers, supported by flexible, usable and useful health IT, can make informed shared decisions about testing and treatment which can lead to more timely, efficient, and higher-value health care.

These results are based on surveys submitted by hospitals across the country that have demonstrated a commitment to transparency by participating in the voluntary Leapfrog Hospital Survey. The survey assesses hospitals on three key areas: how patients fare, resources used in caring for patients, and leadership and structures that promote patient safety. This website also includes information on hospitals’ Hospital Safety Scores.

Latinos are the largest ethnic minority group in the United States, and it’s expected that by 2050 they will comprise almost 30 percent of the U.S. population. Yet they are also the most underserved by health care and health insurance providers.

Latinos’ low rates of insurance coverage and poor access to health care strongly suggest a need for better outreach by health care providers and an improvement in insurance coverage. Although the implementation of the Affordable Care Act of 2010 seems to have helped (approximately 25 percent of those eligible for coverage under the ACA are Latino), public health experts expect that, even with the ACA, Latinos will continue to have problems accessing high-quality health care.

Alex Ortega, a professor of public health at the UCLA Fielding School of Public Health, and colleagues conducted an extensive review of published scientific research on Latino health care. Their analysis, published in the March issue of the Annual Review of Public Health, identifies four problem areas related to health care delivery to Latinos under ACA:

The consequences of not covering undocumented residents.

The growth of the Latino population in states that are not participating in the ACA’s Medicaid expansion program.

The need to increase the number of Latino physicians and non-physician health care providers to address language and cultural barriers.

“As the Latino population continues to grow, it should be a national health policy priority to improve their access to care and determine the best way to deliver high-quality care to this population at the local, state and national levels,” Ortega said. “Resolving these four key issues would be an important first step.”

Insurance for the undocumented

Whether and how to provide insurance for undocumented residents is, at best, a complicated decision, said Ortega, who is also the director of the UCLA Center for Population Health and Health Disparities.

For one thing, the ACA explicitly excludes the estimated 12 million undocumented people in the U.S. from benefiting from either the state insurance exchanges established by the ACA or the ACA’s expansion of Medicaid. That rule could create a number of problems for local health care and public health systems.

For example, federal law dictates that anyone can receive treatment at emergency rooms regardless of their citizenship status, so the ACA’s exclusion of undocumented immigrants has discouraged them from using primary care providers and instead driven them to visit emergency departments. This is more costly for users and taxpayers, and it results in higher premiums for those who are insured.

In addition, previous research has shown that undocumented people often delay seeking care for medical problems.

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As the ACA is implemented and more people become insured for the first time, local community clinics will be critical for delivering primary care to those who remain uninsured.

“These services may become increasingly politically tenuous as undocumented populations account for higher proportions of clinic users over time,” he said. “So it remains unclear how these clinics will continue to provide care for them.”

Massive health program: $34 billion spent on women and children since 2010; New goal: End preventable deaths of women and young children

An ambitious 2010 initiative to improve the health of women and children around the world has turned into the fastest growing global public health partnership in history, attracting $60 billion in resources. Some $34 billion, nearly 60 percent of the total, has already been disbursed.

The Every Woman Every Child movement has now gathered more than 400 commitments by more than 300 partners around the world, ranging from governments and foundations to business, civil society and low-income countries themselves.

The movement stems from the Global Strategy for Women’s and Children’s Health, launched by United Nations Secretary-General Ban Ki-moon in 2010 to accelerate progress towards the Millennium Development Goals (MDGs) for health.

Every Woman Every Child has set off a major wave in attention to improving essential health care for millions of poor women and children. Major gains in the past five years include greater professional maternity care, family planning, prenatal and postnatal care, childhood vaccinations, oral rehydration therapy and improving access to drugs to prevent mother-to-child transmission of HIV.

The result of such increased care is that maternal and child death rates have fallen in every one of the Global Strategy’s 49-targeted countries in the latest four years.

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“The synergy between education and health is evident. Education and health are, quite simply, the drivers of change and development. Education empowers women and girls to live healthier lives and as a result, fewer children are dying. The evidence is clear, better education leads to better health outcomes.

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“One of the most important lessons we have learned through the Millennium Development Goals is that to make progress we need an integrated and multifaceted approach,” says Kathy Calvin, president of the UN Foundation. “Effective partnerships are not just about financing; they also tap into partner expertise, innovation, and resources to deliver results. Every Woman Every Child has shown that when each sector contributes its unique strengths and capacities, we can save lives.”

Keys to progress

Significant improvements in key health indicators mainly in 49-targeted countries during its five-year history of Every Women Every Child include:

In recent weeks, the market has reacted to a few noteworthy headlines, all involved with or touching upon value-based discretionary actions, and many with the not-so-hidden question: What’s In It for Me or WIIFM?

CMS announced that by 2016 30% of fees in health care should be paid for through a value-based system, moving away from fee-for-service.

ACO results have shown ambivalent outcomes.

Outcomes-based contracts have permeated the Hepatitis C cost-nado (that’s a cost sharknado, the kind that fiercely defies cost controls and takes over all noise about payment reform and patient preferences).

Reference-based pricing is a good/bad troublemaker in the middle of the value-based travails.

As one of the loudest proponents on value-based designs, I lift the curtain again to show the thinking behind the movement from fee for service to value-based designs. All of these items above discuss the message of payment reform, or system alignment, but they are intensely linked to the patient-consumer ability to make the right choices, choose the right sites for care, and pay the right amount for services rendered to achieve health security.

And it’s a lot of money – sometimes thousands of dollars, not covered by insurance.

And even patients who are savvy enough to know about these fees before they get the bill have a lot of trouble finding out about them, as Erica Byfield made clear in her strong 3-minute report.

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It’s not unique to Atlanta. She quotes a University of California, Berkeley, studythat found that patients generally pay 10 percent more at hospital-owned practices.

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The ACA does include incentives for “vertical integration,” or having doctors and physicians part of one organization. But it’s not supposed to raise costs. It’s supposed to bring them down by improving efficiency, creating economies and encouraging care coordination. (Some of the fee problems actually stem from Medicare billing practices, not specifically the ACA.)

The Agency for Healthcare Research and Quality (AHRQ), through its EPCs, sponsors the development of various reports to assist public- and private-sector organizations in their efforts to improve the quality of health care in the United States. These reports provide comprehensive, science-based information on common, costly medical conditions and new health care technologies and strategies. The EPCs review all relevant scientific literature on a wide spectrum of clinical and health services topics. EPCs also produce technical reports on methodological topics and other types of evidence synthesis-related reports.

Where do Technology Assessments come from?

The Technology Assessment (TA) Program at the Agency for Healthcare Research and Quality (AHRQ) provides technology assessments for the Centers for Medicare & Medicaid Services (CMS). These technology assessments are used by CMS to inform its national coverage decisions for the Medicare program as well as provide information to Medicare carriers.
Fact sheets and reports can be found through The Technology Assessment (TA) Program

The Evidence Reports/Technology Assessments (ERTAs) and Comparative Effectiveness Reviews (CERs) are provided to Bookshelf by the Agency for Healthcare Research and Quality (AHRQ). AHRQ has a publications clearinghouse, which can be accessed through this link: http://ahrqpubs.ahrq.gov/OA_HTML/ibeCZzpHome.jsp

A patient in a hospital in Cambodia is given some pain killers. Photo: World Bank/Masaru Goto

3 March 2015 – Three quarters of the world population has no access to proper pain relief treatment, according to a report by the United Nations body charged with overseeing Governments’ compliance with international drug control treaties, which was released in London today.

Around 5.5 billion people still have limited or no access to medicines containing narcotic drugs such as codeine or morphine the Vienna-based International Narcotics Control Board (INCB) says in its Annual Report for 2014, which went on to point out that around 92 per cent of all morphine used worldwide is consumed by only 17 per cent of the world population, primarily living in the United States, Canada, Western Europe, Australia and New Zealand.

The report, which calls on Governments to address the discrepancy in order to comply with International Drug Control Conventions, notes that natural disasters and armed conflicts around the world can further limit access to essential medicines and the Board stressed that in cases of emergency medical care, simplified control measures can be applied.

For example in the Philippines following the destruction by Typhoon Haiyan in 2013, the Board pointed out to all countries as well as to providers of humanitarian assistance the simplified procedures for the export, transportation and delivery of medicines containing substances under international control.

In its Report, the INCB notes that drug control measures do not exist in a vacuum and that, in their implementation of the drug control conventions, States must also comply with obligations under other treaties, including international humanitarian law and their international human rights obligations, such as allowing civilians to have access to medical care and essential medicines during armed conflicts.

Additionally, the INCB noted that States were charged with deciding specific sanctions for drug-related offences, but should avoid application of the death penalty for such cases.

To achieve a balanced and integrated approach to the drug problem, Governments also should ensure that demand reduction is one of the first priorities of their drug control policies, while they should put greater emphasis on and provide support and appropriate resources to prevention, treatment and rehabilitation, the Report says.

Among the rest of the Report’s findings were an increase in the number of new psychoactive substances (NPS) by 11 per cent and a 66 per cent increase in global consumption of methylphenidate, a stimulant primarily used in the treatment of Attention Deficit Hyperactivity Disorder (ADHD).

The Report also pointed out that the legalization of production, distribution, sale and consumption of cannabis and its derivatives for recreational purposes in Uruguay, together with the moves by States in the United States to legalise sale and distribution of cannabis for non-medical purposes, ran counter to article 4 of the 1961 Single Convention on narcotic drugs, which requires States to limit the use of narcotic drugs to medical and scientific purposes.

If you want a refresher on how far society has come on dealing with end-of-life care issues — and what issues are still to be resolved — then this retrospective article in the Feb 12 issue of the New England Journal of Medicine from experts at The Hastings Center is a great place to begin. It reviews the history of the end-of-life care movement in the U.S., takes a look at the integration of palliative care into health care delivery, discusses the still controversial “death with dignity” laws and ethical issues like removal of feeding and hydration tubes.

I recently spoke with co-author Nancy Berlinger, Ph.D., a research scholar at Hastings, about how the conversation on death and dying has changed over four decades.

Q: Why did you and your colleagues develop this retrospective for publication in a medical journal?

We see lots of ads from hospitals advertising their standards of excellence and their programs. None of them ever advertise their end of life care.

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it’s clear that financial incentives are very misaligned with what people need, what they want, what would be medically appropriate. This is a very complex issue – it can’t be undone by a patient, or by an individual doctor or nurse. This has to be the focus of very high-level attention.

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Q: What should journalists be focusing on?

NB: Even if they don’t cover the deep medical end of things, they can still ask questions in the context of health and wellness, such as:

How much power does a sick person have?

How much power does a really stressed out family have?

How much power does a doctor, seeing X number of patients, really have?

And, what still do we want to try to help these people to do? To understand we’re all connected in these efforts.

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About

This blog presents a sampling of health and medical news and resources for all. Selected articles and resources will hopefully be of general interest but will also encourage further reading through posted references and other links. Currently I am focusing on public health, basic and applied research and very broadly on disease and healthy lifestyle topics.

Several times a month I will post items on international and global health issues. My Peace Corps Liberia experience (1980-81) has formed me as a global citizen in many ways and has challenged me to think of health and other topics in a more holistic manner. (For those wishing to see pictures of a 2009 Friends of Liberia service trip to this West African country, please visit www.fol.org. My photo album is included).

Do you have an informational question in the health/medical area?
Email me at jmflahiff@yahoo.comI will reply within 48 hours.

My professional work experience and education includes over 10 years experience as a medical librarian and a Master’s in Library Science. In my most recent position I enjoyed contributing to our library’s blog, performing in depth literature searches, and collaborating with faculty, staff, students, and the general public.

While I will never be be able to keep up with the universe of current health/medical news,
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